While it’s still unclear exactly how the coronavirus pandemic will play out in the U.S., we can say that at least right now, things don’t look good. A report from Johns Hopkins published at the end of February makes predictions based on the 1918 Spanish flu pandemic (a “very severe scenario”) and the lesser known 1968 flu pandemic (a “moderate scenario”). In both cases, some 38 million people would need medical care of some kind in the U.S. In estimates leaked to the New York Times, the Centers for Disease Control and Prevention projects that in various COVID-19 scenarios, 2.4 million to 21 million people might need hospitalization, and—it’s hard to take in these numbers—200,000 to 1.7 million might die. The idea with flattening the curve, of course, is to spread out the need for intensive care as much as possible. But given that there are only about 46,500 ICU beds in the U.S.—and maybe resources to double that, in an emergency—hospitals should be planning “for the graceful transition to contingency and crisis standards of care,” write authors Eric Toner and Richard Waldhorn. “In a severe pandemic, not all patients in need of intensive care will be able to be accommodated in the ICU.”
We’ve been hearing a lot about the ethical choices that doctors will have to make around ICU beds. But beds are just the start of the problem. Masks are already on the brink of running out for some hospitals, which means clinicians are reusing masks, or even prototyping their own out of other surgical supplies. The CDC issued guidelines saying that flimsier surgical masks would do, to protests from people on the front lines. “The biggest concern for hospitals right now is what they call surge capacity, and being able to meet the demand for care in the coming weeks,” says Lisa Romano, the chief nursing officer with CipherHealth, a company that makes software to help hospitals manage communication with patients and care.* “That surge capacity is not just a physical bed, or location in the hospital—it’s the health care resource of staffing and equipment.”
Hospitals are already adjusting—and in many cases lowering—standards of care across the board, hoping that this will help them accommodate a surge of critically ill patients. One main way to free up staff and resources that many hospitals are doing is to delay elective surgeries. Any surgery that requires a patient to go fully under anesthesia uses a ventilator, so delaying them can relieve a little bit of strain on the most critical equipment need. Delaying elective surgeries also relieves staff and nurses to instead focus their work on critically ill patients. Elective surgeries can be really important, though—yes, they’re things that are not an emergency, but they include operations like removing brain tumors and kidney stones. Deciding what falls into this category is something of a judgment call, and a particularly tough one given our current lack of knowledge about how long this might last.
Hospitals are also turning to telehealth to ease the flow of patients coming through their physical doors. Video visits, which in many cases do not detract from the level of care in, say, initial consultations or routine follow-up visits, can allow patients with mild symptoms, or concerns unrelated to COVID-19, to stay home and practice social distancing while they get medical advice, reducing the risk of contracting or spreading the coronavirus while easing the burden on doctors. “With telemedicine, we can expand our system’s triage capabilities to avoid wasted efforts and to handle surges,” Jules Lipoff, chair of the teledermatology task force of the American Academy of Dermatology, wrote in Slate. “Most clinical decisions likely can be made by providers not physically present with patients.” On Tuesday, the Centers for Medicare and Medicaid Services loosened restrictions on video visits so that Medicare covers video visits for more people.
CMS also loosened restrictions to allow doctors to use Skype and FaceTime as needed, which are not allowed typically because they are not compliant with health privacy laws (they pose a greater privacy risk). This is a warranted move given the circumstances, but it also leaves systems more vulnerable to hackers and the leaking of sensitive health data. Video platforms also rely on patients having stable internet connections and webcams, which isn’t a given. And insurers in all states are not required to cover video visits—it’s unclear how and if patients that have a plan that does not cover video will be accounted for when all of this is said and done.
Some hospitals are changing their processes on how they deliver sensitive test results. CipherHealth set up a system this week with UCSF to tell people their results through an automated message, says Romano, which included instructions on how to ride the virus out at home if the symptoms are mild. Putting a robot, essentially, on this tasks frees up bandwidth for hospital staff to do something else, like answer hotline calls, or screen patients at the door of a hospital for symptoms like coughing and signs of fever. Automating calls with results also might mean you’ll get your result slightly faster—an automated process can reach out to many people at once. “You can get into moral and ethical debates about using automation to deliver a sensitive result,” says Romano. “The reality is we are in a public health crisis.”
All of this means that if they can, patients should try to stay out of the health care system as much as possible, both to avoid risk of exposure and to free up their doctors to work on urgent tasks “There are a lot of follow-up visits in which elderly patients come to see their doctor—now they’re not coming [if] they’re not sick,” a clinician who works with elderly patients told me. (She wished to be anonymous because “my boss is so stressed that if I say anything to her” about getting permission to talk to a reporter “it’s going to be breaking the camel’s back.”) “Follow-ups are super important in a regular time, but not absolutely essential.” If you’re feeling a little ill, or do need a follow-up, see if your insurance offers a video doctor visit first; a clinician can help you get meds quickly from afar and advise you on whether you really do need to head to a brick-and-mortar office.
Clinicians are considering the risks they face from the surge of patients. A question that Dean Blumberg, chief of pediatric infectious diseases at UC–Davis Health, keeps getting from clinicians: If they live with or care for someone with a weak immune system, or who is elderly, should they keep coming into work? Blumberg—who has been holding Q&As to get his staff up to speed, since written presentations need to be updated too quickly—says that it’s a personal decision. Staying home means not being able to contribute to the greater good when it’s all hands on deck, but going to work means a greater risk of contracting the virus. Workers aren’t making the choice to stay home yet, “I’m seeing a lot of people thinking about it,” says Blumberg.
“There’s so much anxiety,” says Blumberg. As one doctor—who also wished to be anonymous—told me, “I think we’re going to be caught off guard on something we haven’t thought about yet.”
Correction, March 24, 2020: This post originally misidentified CipherHealth as a company that manages patient flow. It manages communication with patients.